FOOT AND ANKLE DISORDERS


See also Tarsal Tunnel Syndrome and Achilles Tendon Rupture

I. Sprains
  1. Most common type of ankle injury
  2. Most common mechanism of injury is inversion + plantarflexion
  3. Common grading scheme
    1. "Grade I": Microscopic tears, mild swelling and tenderness, can bear weight with minimal pain
    2. "Grade II": Incomplete tear, moderate pain, ecchymosis, swelling, and tenderness; significant pain with weight bearing and ambulation; mild-mod joint instability; some loss of ROM
    3. "Grade III": Complete tear of ligament with severe pain, tenderness, swelling, and ecchymosis; joint instability; and inability to bear weight
  4. "Ottawa Ankle Rules" algorithm-Likelihood of fracture (and thus, utility of x-rays), very low if ALL of the following are true:
    1. Patient able to bear weight both immediately after injury and at presentation
    2. None of the following are present:
      1. Tenderness on posterior aspect or tip of medial malleolus
      2. Tenderness on posterior aspect or tip of lateral malleolus (note-tenderness over anterior aspect of lateral malleolus is common with ankle injuries and does not count)
      3. Tenderness over navicular bone
      4. Tenderness at base of 5th metatarsal
  5. Note: Medial ankle injuries tend to be more severe since the deltoid ligament requires more force to be injured
  6. Management
    1. "PRICE" mnemonic (protection, rest, ice, compression elevation)
    2. Grade I:
      1. Elastic ("Ace") wrap can aid in comfort
      2. Immobilization is not indicated
      3. Weight-bearing mobilization in first week
      4. One-time physical therapy visit and 4wks of home exercises can speed recovery
    3. Grade II:
      1. Ankle stirrup brace ("Aircast") can aid in comfort and provides more support than elastic wrap
      2. Weight-bearing mobilization in first week
      3. One-time physical therapy visit and 4wks of home exercises can speed recovery
    4. Grade III:
      1. No clear evidence to indicate whether early mobilization vs. immobilization result in better outcomes
  7. Secondary prevention
    1. Semirigid orthoses or ankle stirrup braces reduce recurent ankle injuries per a 2011 Cochrane review (RR 0.5)
II. Tarsal coalition
  1. Fusion of 2 or more tarsal bones
  2. Typically occurs mid-to-late adolescence
  3. 50% have it on both ankles
  4. Clinical presentation includes ankle pain, decreased hindfoot ROM, and pain on inversion of the foot
III. Os Trigonum
  1. Non-ossification of cartilage of heel
  2. Unsually unilateral
  3. Causes heel tenderness
IV. Sever's apophysitis
  1. Inflammation of calcaneal apophysis
  2. Presents with heel pain
V. Tendinopathy of posterior tibial tendon
  1. The posterior tibial tendon is essential for plantarflexion and inversion of the foot as well as stabilization of the arch
  2. Injury can contribute to chronic flatfoot
  3. Most common mechanism of injury is stepping into a hole
  4. Most common in women over 40
  5. Injury can lead to degeneration and tendon rupture
  6. Px: Pain with resisted plantarflexion of foot; Pain and absence of the normal varus deviation of the heel when patient stands on tiptoe
  7. Treatment: immobilizatio in cast boot or short leg cast for 2-3wks
VI. Congenital foot deformities
  1. Metatarsus adductus
    1. Most common foot deformity in newborns
    2. Related to intrauterine positioning
    3. Examination findings
      1. Adducted forefoot (turned toward midline)
      2. May be possible for examiner to passively abduct the foot beyond midline ("flexible metatarsus adductus")
    4. Management
      1. If flexible, treated with gentle stretching with each diaper change
      2. If partially flexible or not flexible, or suspect metatarsus varus or clubfoot (see below), refer to ortho for consideration for casting
  2. Metatarsus varus aka "skewfoot"
    1. Also involves adduction of forefoot, but also get heel valgus ("out-turning")
    2. Less common than metatarsus adductus
    3. Often treated with serial casting x 6-8wks or surgery in extreme cases
  3. Clubfoot
    1. Also involves adduction of forefoot, but also get heel varus ("in-turning") as well as ankle equinus ("down-pointing") and plantarflexion of first toe metatarsal ("cavus deformity), creating a high arch.
    2. Less common than metatarsus adductus
    3. More common in boys
    4. Bilateral in 50% of cases
    5. May be identifiable on prenatal ultrasound and can be associated with other congenital abnormalities including neurologic, cardiac, and urogenital
    6. Treatment
      1. Depends on scores on standardized scales e.g. Pirani, Dimeglio
      2. Mild cases can be treated with expectant management
      3. Treatment should begin within first 7-10d of life
      4. Moderate cases treated with serial casting using the "Ponseti method"
      5. More severe cases treated with casting + tenotomy of Achilles tendon to relieve equinus
      6. Bracing after casting to prevent recurrence (full-time x 3mos then when asleep until 3-4y)
      7. More aggressive surgical treatment by soft-tissue release is not thought to result in better outcomes than above approach

 VII. Intoeing in children

  1. Internal tibial torsion
    1. Most common in toddlers
    2. Bilateral in 2/3 of cases
    3. Parents may report that child "trips" frequently
    4. On exam, see increase in internal rotation of foot relative to thigh beyond normal 5-10' of external rotation.
    5. Usually resolves spontaneously
    6. Parents should discourage children from sitting with their feet tucked under them Can be treated surgically if present in children with functional issues (frequent falling), thigh-foot angle > 15' of internal rotation, or persistence beyond age 8.
  2. Increased femoral anteversion
    1. Most common in early school-age children
    2. Usually bilateral
    3. Exam shows:
      1. Patellae pointing inward when observed walking
      2. May appear "uncoordinated" while walking
      3. See increased internal rotation and decreased external rotation of hips
      4. Need to do careful neurologic exam for ROM, spasticity, hyperreflexia, etc. to detect neuromuscular disorders e.g. cerebral palsy.
    4. Usually increases until age 5yo then resolves spontaneously by 8yo Surgery considered if persists > 8yo or significant functional impact
(Sources include Core Content Review of Family Medicine, 2012)